OBJECTIVE:Abdominal pain is a common emergency department (ED) presentation. Currently, there is limited Australian literature detailing whether biological sex results in differences in analgesia provision for abdominal pain. The primary aim of this study is to determine whether there is a difference in time to analgesia administration based on biological sex for patients presenting with abdominal pain to the ED. METHODS:This was a retrospective, single centre cohort study of adult patients presenting to the Royal Melbourne Hospital ED between April 1st and 30th 2024 with abdominal pain. Data relating to the patient's presentation and management were collected from records of eligible patients. RESULTS:Of 708 eligible patients, 292 (41%) were biologically male and 416 (59%) female. There were 559 (80%) patients who received at least one dose of analgesia. Females waited a median of 75 min and males 59 min to receive their first dose of analgesia (difference in medians = 16 min, 95% confidence interval [CI] 0.9-31.0 min, p = 0.04). Females were also nearly half as likely to receive parenteral analgesia (OR 0.56, 95% CI 0.38-0.82, p = 0.003). We found minimal differences in diagnoses, triage category or pain scores between sexes. CONCLUSION:Females presenting to the ED with abdominal pain are waiting longer than males to receive their first dose of analgesia and are less likely to receive parenteral analgesia. Further research is required to determine the reason for this discrepancy and to then remediate it.

BACKGROUND:Headache is a common emergency department (ED) presentation. We aimed to determine the proportion of patients undergoing Computerised Tomography (CT) for non-traumatic headache and identify factors influencing clinician decision-making. METHODS:We conducted a retrospective chart review of adult ED presentations at the Royal Melbourne Hospital from January to March 2024. Clinical features and CT data were extracted and mapped against SNOOP4 features. RESULTS:Among 223 patients, 124 (55.6 %) underwent CT, with abnormal findings in 15.3 % (19/124). No patient-reported symptoms increased the likelihood of CT ordering; photophobia was negatively associated (Odds Ratio (OR)= 0.41, 95 % Confidence Interval (CI):0.22-0.79). Examination abnormalities in peripheral sensation (OR=13.04, 95 %CI:1.69-100.59) and strength (OR= 3.62, 95 %CI:1.00-13.09) increased CT use. Patients with > 2 SNOOP4 features had markedly higher odds of receiving CT (OR= 13.5, 95 %CI:3.12-58.34) and of abnormal findings (OR= 5.75, 95 %CI:2.03-16.27). CONCLUSIONS:CT neuroimaging for non-traumatic headache was frequently performed, with a relatively low abnormal yield. While patient-reported symptoms did not influence CT ordering, examination findings and cumulative SNOOP4 features were associated with both imaging decisions and abnormal results. These findings support future studies into red-flag-based pathways to guide purposeful CT use.

OBJECTIVES:To describe the historical and current use of recreational drugs by a trial cohort of youth presenting to the emergency department (ED) whilst experiencing acute behavioural disturbance (ABD). METHODS:This was a secondary analysis of a randomised, controlled trial comparing medication management of ABD in children and adolescents aged nine to 17 years who were deemed to require oral sedative medication. RESULTS:Recreational drugs were used by 33% of participants any time prior to enrolment (115/348). Cannabis was the most commonly used (87/348, 25%), followed by amphetamines/methamphetamines (32/348, 9%) and benzodiazepines (26/348, 7%). CONCLUSION:Recreational drug use may be a contributing factor to ABD amongst children and adolescents presenting to EDs.

AIM:To describe the epidemiological characteristics of children and young people presenting to the emergency department (ED) with acute severe behavioural disturbance (ASBD) who were deemed to require oral sedative medication. METHODS:Secondary analysis of a randomised controlled open-label multi-centre trial of oral olanzapine versus oral diazepam for the management of ASBD in children and young people aged nine to 17 years for whom epidemiological data were recorded. RESULTS:There were 348 participants enrolled in the randomised controlled trial (RCT). The majority were female (215/348, 62%) with a mean age of 14.6 years (standard deviation 2.2). The most common pre-existing medical or mental health condition was anxiety (122/299, 35%) followed by attention deficit hyperactivity disorder and autism spectrum disorder (33% and 32%, respectively). Two-thirds of the study population (216/348, 62%) had previously attended the ED for ASBD management and 61% (212/348) reported previous intentional self-harm. Nearly three-quarters (247/348, 71%) were accessing psychiatric care in the community prior to their ED presentation. Half of the study population (178/348, 52%) presented to the ED with emergency services (e.g., ambulance, police). The median length of stay in the ED was 5.7 h (interquartile range 3.9-10.2 h) and 28% (98/348) of study participants required admission to hospital. CONCLUSIONS:For children and young people presenting to the ED with ASBD who were deemed to require oral sedative medication to assist with behavioural containment, pre-existing mental health disorders were common. There is a need for focussed management procedures for more targeted, trauma-focussed care for children and young people presenting to the ED with ASBD and for support and education in the pre-hospital setting. TRIAL REGISTRATION:The primary study (PEAChY-O) was registered with the Australian and New Zealand Clinical Trials Registry (ANZCTR) (ACTRN12621001236886) prior to commencement.

Objective To describe the frequency and nature of non-pharmacological de-escalation methods used for children and adolescents presenting to emergency departments (EDs) with acute severe behavioural disturbance (ASBD).Design Secondary analysis of a randomised, controlled, open-label, multicentre trial of oral olanzapine versus oral diazepam for the management of ASBD.Setting Nine EDs in Australia between October 2021 and November 2023.Participants Children aged 9-17 years, for whom information on non-pharmacological de-escalation attempts was recorded, who ultimately required oral sedative medication to manage their ASBD.Main outcome measures The frequency and nature of the use of non-pharmacological de-escalation methods for children and adolescents presenting to EDs in a state of ASBD.Results There were 348 participants enrolled in the randomised controlled trial. This study reports on the 337 of 348 participants (97%) for whom information was recorded regarding non-pharmacological de-escalation attempts during the trial period. Verbal de-escalation was the most commonly attempted technique (96%) followed by active listening (75%). The frequency and nature of de-escalation techniques used were similar across the nine participating sites.Conclusions A variety of non-pharmacological de-escalation strategies are used among patients who require oral sedative medication. There is a need for studies to investigate whether there are optimal first-line de-escalation strategies and to determine their effectiveness and order of use in children and adolescents presenting to EDs with ASBD.

OBJECTIVE:Hypocalcaemia is a common electrolyte disturbance in major trauma patients, particularly those with haemorrhagic shock. Trauma patients are often intubated as part of their care, which can result in post-induction hypotension. We aimed to estimate the effect of hypocalcaemia on post-induction hypotension. METHODS:We conducted a retrospective observational study of trauma patients ≥ 18 years old intubated in a tertiary Australian Emergency Department between 1st January 2020 and 30th September 2024. Epidemiological and clinical management data were extracted to estimate the effect of hypocalcaemia on outcomes. RESULTS:Of 478 eligible patients, 151 had available haemodynamic and calcium measurements. Post-induction hypotension occurred in 38/47 (81%) of hypocalcaemic and 69/104 (66%) of non-hypocalcaemic patients. Hypocalcaemia was associated with higher odds of post-induction hypotension (adjusted odds ratio [aOR] 2.15, 95% confidence interval [CI] 0.84-5.51), with considerable uncertainty in this estimate. Hypocalcaemic patients were more likely to receive red blood cells within 15-min post-induction (OR 2.13, 95% CI 1.12-4.04). Minimal differences were observed in cardiac arrest 15-min post-induction (OR 0.65, 95% CI 0.07-5.73) or mortality at discharge (OR 1.00, 95% CI 0.51-1.97). CONCLUSIONS:Hypocalcaemia may be associated with higher odds of post-induction hypotension in trauma patients; however, our findings require corroboration across a larger multi-centre prospective observational study. If corroborated, a randomised controlled trial is warranted to establish the utility of calcium replacement for the prevention of post-induction hypotension.

Ordinal outcomes are becoming increasingly common in clinical research because they can incorporate multiple clinical states into a single outcome, offer increased statistical power compared to binary outcomes, and can be applied across a range of illness severities. However, ordinal outcomes may be unfamiliar to many clinicians and researchers. In this paper, we aim to provide a practical conceptual overview of ordinal outcomes in the context of emergency medicine, discuss their pros and cons, and describe the associated effect measures and statistical methods that can be used to estimate them. We describe the different types of ordinal outcomes, including hierarchical composite endpoints (e.g., Desirability of Outcome Ranking or DOOR); outline the target parameters that may be of interest, such as the common odds ratio and win ratio; and describe the statistical methods for estimating these parameters, including their assumptions and limitations. Ordinal outcomes offer a flexible, efficient, and nuanced way to measure treatment effects but require careful planning for how treatment effects will be estimated and communicated. We hope this review will make these outcomes more accessible for clinical researchers.

Objectives To describe the experience of health care professionals involved in the care of young people with acute severe behavioral disturbance across the acute care setting. Methods We used purposive and snowball sampling to recruit paramedics, nurses, doctors, and mental health clinicians caring for young people with acute severe behavioral disturbance in the prehospital and/or emergency department environments. We conducted one-to-one telephone-based semistructured qualitative interviews with each staff member. The audio recordings were transcribed verbatim, and participant pseudonyms were assigned. We iteratively developed a thematic coding structure. Data collection continued until thematic saturation was reached. Results We interviewed 31 health care professionals—12 doctors, 5 nurses, 7 mental health clinicians, and 7 paramedics. Participants outlined factors they felt contributed to the young person’s behavioral disturbance. They detailed the management strategies used. Participants spoke about their exposure to physical violence while managing these young people and the challenges of balancing patient and staff safety. There was a significant personal impact on participants through providing care to this cohort. Participants acknowledged the workflow, staff resource, and bystander impacts of these presentations. Conclusion Based on participant’s experiences, health care staff aim to provide high-quality care to young people with behavioral disturbance in circumstances that present risks to their safety. There is variability in the way staff are currently managing these young people likely because of the limited high-quality evidence currently available, highlighting key areas for future research.

OBJECTIVES:Paediatric mental health presentations to emergency departments (EDs) are rising. Rural/Regional mental health service users face structural barriers to accessing general and specialist treatment, including physical distance and local service capacity and funding constraints. However, differences in patient characteristics and treatment pathways between major city and rural/regional EDs remain unclear. This study aimed to compare demographic and clinical profiles of paediatric mental health patients within each location. METHODS:Retrospective cohort study of paediatric (aged 0-17 years) mental health presentations at 23 Australian EDs (metropolitan=18, rural/regional=five) from 1 January to 31 December 2018. At each site, up to 100 randomly selected unique patient medical records were included. Demographic and clinical characteristics were compared using logistic and linear mixed effects regression models. RESULTS:2234 young people were recruited (metropolitan=1803, rural/regional=431). Mean age was 14.4 years (SD=2.6) and 59.4% were female. Frequent presentation reasons were suicidal ideation (853; 38.2%), self-harm (668; 29.9%) and behavioural disturbance (306; 13.7%). Of those with complete documentation, 703 (70.9%) had family history of mental illness and 933 (41.8%) reported recent interpersonal difficulties (eg, family/peer conflict). Three hundred and twenty-nine young people (14.7%) were admitted and 1024 (45.8%) were referred to public child and adolescent mental health services (CAMHS). Patients in rural/regional settings had shorter median waiting times for ED clinicians (24 vs 42 min) and mental health assessments (1.1 vs 2.5 hours), shorter median ED length of stay (2.9 vs 4 hours) and higher likelihood of referral to CAMHS on discharge (OR 2.19, 95% CI 1.22, 3.93). CONCLUSIONS:Characteristics of children and adolescents presenting with mental health concerns are broadly similar between metropolitan and rural/regional EDs, but treatment characteristics differ. Frequency of family mental illness and interpersonal difficulties highlights the benefits of family focused interventions. Given similar patient profiles, equitable resourcing of rural/regional services is warranted.

Study objective: To determine whether oral olanzapine or oral diazepam was more effective at achieving behavioral containment for young people presenting to the emergency department with acute severe behavioral disturbance. Methods: We conducted an open-label, multicenter, randomized controlled trial from October 22, 2021, to November 6, 2023. We enrolled young people aged between 9 and 17 years with acute severe behavioral disturbance deemed to require oral medication across 9 Australian emergency departments. We randomly assigned participants to a single weight-based oral dose of olanzapine or diazepam. The primary outcome was successful sedation (Sedation Assessment Tool score less than or equal to 0) without the need for additional sedatives one hour postrandomization. Secondary outcomes included adverse events; length of stay; aggression toward staff, participants, or parent/guardians; disposition; and satisfaction with care. Results: We recruited 348 participants, with 176 assigned to olanzapine and 172 to diazepam. Successful sedation without the requirement for additional sedatives occurred in 103/168 (61%) in the olanzapine group and 90/158 (57%) in the diazepam group (adjusted risk difference 3.6%, 95% confidence interval-6.7% to 14.0%). No serious adverse events were reported in either group. Conclusions: There was no evidence that oral olanzapine resulted in a greater proportion of participants with acute severe behavioral disturbance achieving successful sedation at one hour postrandomization than oral diazepam. Neither medication resulted in any serious adverse events; however, approximately 40% of participants in each group did not achieve successful sedation.

The Paediatric Research in Emergency Departments International Collaborative (PREDICT) has operated as an emergency research network in Australia and Aotearoa New Zealand for 20 years. A focus on both knowledge generation and, over the last decade, knowledge translation research has produced more than 200 network publications. Active research sites have increased from the original 12 sites to 47, with enhanced representation of where children with acute illness present in both countries. We outline ongoing challenges across the network, which will be relevant for those providing acute paediatric care and to other emergency clinicians interested in multicentre research collaboration.

OBJECTIVES:To determine the frequency and clinical consequences of discrepancies in skeletal radiograph interpretation between emergency and radiology doctors in an Australian ED. METHODS:We reviewed the records of adult and paediatric patients assessed with skeletal radiography in an ED in Victoria, Australia over 3 months (January to March 2022). Epidemiological data, the interpretation of the radiograph by ED and radiology doctors, and clinical management of the patient were recorded to determine interpretation discrepancies and the consequences of these. RESULTS:There were 2359 unique skeletal radiographs in 1576 patient presentations during the study period. Of these, 140 (6%) had a discrepancy. Where a discrepancy existed, 47% of the ED interpretation reported a fracture and/or dislocation which was not present in the radiology interpretation (false positive), whereas the remaining (53%) were attributed to a missed fracture and/or dislocation (false negative). Thirty-five discrepancies (2%) required a change in patient management and were therefore clinically significant. The most commonly affected body region was the elbow, where 15% of radiographs were discrepant. Pathology was more often missed when multiple abnormalities were present on the same radiograph (odds ratio = 4.2, 95% confidence interval = 2.5-6.8). CONCLUSION:The rate of clinically significant discrepancies in the interpretation of skeletal radiographs by emergency medicine doctors is low. This data support using the ED interpretation of radiographs to guide initial management as safe practice.

AimTo characterise key features of young people presenting to the emergency department (ED) with a mental health complaint when comparing children (aged 7 to 12 years) and teenagers (13 years and greater).MethodsRetrospective review of all ED mental health presentations in children aged 7–17 years presenting over a 12‐month period in 2018 to a tertiary children's hospital in Victoria, Australia. Univariate analyses were carried out to examine the relationship between children and teenagers and a number of key presentation variables. Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were calculated for ED management outcomes.ResultsThere were 1691 ED mental health presentations in 2018. Of these presentations, 407 (24%) were children aged 12 years or less. The remaining 76% (1284) were teenagers. The younger aged cohort were more likely to be male (OR 2.43, CI 1.92–3.08) and have a past history of autism spectrum disorder (OR 1.92, CI 1.45–1.84). They were more likely to have a presenting complaint of acute behavioural disturbance (OR 2.03, CI 1.59–2.60), be physically restrained (OR 2.01, CI 1.18–3.37) and have sedative medication provided (OR 2.87, CI 1.63–5.04). The older aged cohort were more likely to have a past history of depression (OR 0.19, CI 0.12–0.29) and a presenting complaint of intentional self‐poisoning (OR 0.33, CI 0.15–0.65).ConclusionsChildren aged 12 years or less represent one‐quarter of all young people presenting to the ED with a mental health concern. They experience high rates of acute behavioural disturbance and are more likely to require restrictive interventions during their presentation.

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effectiveness and safety profiles of different parenteral medications for the management of acute severe behavioural disturbance in the emergency department setting. These medications are required following the failure of less restrictive means of controlling the patient's behavioural disturbance.

OBJECTIVE To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED. METHODS A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs). RESULTS Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8). CONCLUSIONS Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

ObjectiveResults Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in EDs. It poses a significant risk to the patient and those around them. Little is known about the epidemiology or most effective management in the paediatric population. The aim of the present study is to clarify the practice of senior emergency doctors in Australia when managing paediatric ASBD. Methods The present study was a voluntary electronic questionnaire distributed to and undertaken by senior medical staff in EDs affiliated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network. Respondents reported on exposure to and confidence in managing paediatric ASBD and their current practices. A total of 227 (33%) clinicians completed the survey between February and May 2020. Most clinicians were caring for at least two young people with ASBD each week (72%), felt confident regarding the majority of components of management and referred to local clinical practice guidelines (69%). Agitation/sedation rating scales were seldom used (19%). There was a significant variation in self-reported management practices. The choice of whether to use medication at all, the medication chosen and route of administration all varied greatly. Respondents were more willing to provide parenteral medication to young people reported as having recreational drug intoxication (84%) than those with neurodevelopment disorders (65%) when the same degree of agitation was reported. Conclusions Within Australia, there is considerable variation in paediatric ASBD practice, in particular regarding medication provision. Further prospective research is required to inform best clinical practice.

Introduction Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated risks to patients, families and caregivers, there is limited evidence to guide the most effective pharmacological management in children and adolescents. The aim of this study is to determine whether a single dose of intramuscular olanzapine is more effective than intramuscular droperidol at successfully sedating young people with ASBD requiring intramuscular sedation. Methods and analysis This study is a multicentre, open-label, superiority randomised controlled trial. Young people aged between 9 and 17 years and 364 days presenting to an ED with ASBD who are deemed to require medication for behavioural containment will be recruited to the study. Participants will be randomised in a 1:1 allocation between a single weight-based dose of intramuscular olanzapine and intramuscular droperidol. The primary outcome is the proportion of participants who achieve successful sedation at 1-hour post randomisation without the need for additional sedation. Secondary outcomes will include assessing for adverse events, additional medications provided in the ED, further episodes of ASBD, length of stay in the ED and hospital and satisfaction with management. Effectiveness will be determined using an intention-to-treat analysis, with medication efficacy determined as part of the secondary outcomes using a per-protocol analysis. The primary outcome of successful sedation at 1hour will be presented as a percentage within each treatment group, with comparisons presented as a risk difference with its 95% CIs. Ethics and dissemination Ethics approval was received from the Royal Children's Hospital Human Research Ethics Committee (HREC/69948/RCHM-2021). This incorporated a waiver of informed consent for the study. The findings will be disseminated in a peer-reviewed journal and at academic conferences. Trial registration number ACTRN12621001238864.

Objectives With an increasingly dynamic global illicit drug market, including the emergence of novel psychoactive substances, many jurisdictions have moved to establish toxicosurveillance systems to enable timely detection of harmful substances in the community. This paper describes the methodology for the Emerging Drugs Network of Australia - Victoria (EDNAV) project, a clinical registry focused on the collection of high-quality clinical and analytical data from ED presentations involving illicit drug intoxications. Drug intelligence collected from the project is utilised by local health authorities with the aim to identify patterns of drug use and emerging drugs of concern. Methods The project involves 10 public hospital EDs in Victoria, Australia. Patients 16 years and over, presenting to a network ED with a suspected illicit drug-related toxicity and a requirement for venepuncture are eligible for inclusion in the study under a waiver of consent. Clinical and demographic parameters are documented by site-based clinicians and comprehensive toxicological analysis is conducted on patient blood samples via specialised forensic services. All data are then deidentified and compiled in a project specific database. Results Cases are discussed in weekly multidisciplinary team meetings, with a view to identify potentially harmful substances circulating in the community. High-risk signals are escalated to key stakeholders to produce timely and proportionate public health alerts with a focus on harm minimisation. Conclusions The EDNAV project represents the first centralised system providing near real-time monitoring of community drug use in Victoria and is fundamental in facilitating evidence-based public health intervention.

STUDY OBJECTIVES:To describe the epidemiological factors of mental health presentations in young people to emergency medical services (EMS) and define those experiencing acute severe behavioral disturbance by reviewing parenteral sedation use. METHODS:We performed a retrospective review of records of EMS attendance for young people (aged <18 years) with mental health presentations between July 2018 and June 2019 to a statewide EMS system in Australia of a population of 6.5 million persons. In addition, epidemiological data and information about parenteral sedation for acute severe behavioral disturbance and any adverse events were extracted from the records and analyzed. RESULTS:A total of 7,816 patients had mental health presentations with a median age of 15 years (IQR 14-17). The majority (60%) were female. These presentations accounted for 14% of all pediatric presentations to EMS. Out of them, 612 (8%) received parenteral sedation for acute severe behavioral disturbance. A number of factors were associated with increased odds of parenteral sedative medication being used, including autism spectrum disorder (odds ratio [OR] 3.3; confidence interval [CI], 2.7 to 3.9), posttraumatic stress disorder (OR 2.8; CI, 2.2 to 3.5) and intellectual disability (OR 3.6; CI, 2.6 to 4.8). The majority (460, 75%) of young people received midazolam as their first-line medication, with the remaining patients being provided ketamine (152, 25%). No serious adverse events were noted. CONCLUSION:Mental health conditions were a common presentation to EMS. A history of autism spectrum disorder, posttraumatic stress disorder, or an intellectual disability increased the odds of receiving parenteral sedation for acute severe behavioral disturbance. Sedation appears generally safe in the out-of-hospital setting.